REVIEW OF LITERATURE

CHAPTER TWO

REVIEW OF LITERATURE

2.0.0.0 Introduction

With computerization, knowledge management has become complex. Scholars,

writers, researchers go on adding inputs into various subjects. The fathom of

knowledge ocean goes on increasing each day. What is important is that the reader

sifts this available information to his use. It gives insight as to what has been done so

far and what needs to be done in future. This assists in avoiding duplication and

highlighting specific areas of research. Therefore, the researcher took up mammoth

task of surveying available literature relating to specific field of research.

Undoubtedly, internet is comprehensive, one spot destination to scroll most of

literature. Details are available in books/periodicals etc. Many libraries, book stores

and literature of hospitals, municipal corporations, companies dealing with products

related to hospital waste management were read extensively at various stages of this

research. Some references were referred to repeatedly. The researcher has also

subscribed to life membership of INDIAN SOCIETY OF HOSPITAL WASTE

MANAGEMENT (ISHWM), DWARKA, NEW DELHI (Membership number 326).

This gave opportunity to lot of literature specific to research topic. The researcher also

got opportunity to attend various seminars/workshops conducted at international/

national level by this august establishment in the country. Interaction with Rear

Admiral (Retd) Lalji Verma, President of this organization, FATHER OF HOSPITAL

WASTE MANAGEMENT IN INDIA, and various other luminaries was very special

for this researcher. This researcher was also participant in seminar conducted jointly

by ISHWM, and King George’s Hospital Lucknow. The event was an eye opener for

fresh scholar.

Review of literature thus helped the researcher to gain background knowledge about

hospital waste management. This helped in identifying the concepts relating to

medical waste to find out potential relationship between them and thus guided the

researcher to formulate researchable objectives. It also guided the researcher to

formulate appropriate methodology, research design, methods of measuring the

concepts and formulating techniques of analysis. It helped the investigator to identify

data resources used by other researchers, and try to learn how others have structured

their reports. Keeping main theme of research problem in mind the researcher thus

classified review of related literature.

During Course work I, and II at JJTU, the researcher was asked to submit literature

reviews of 5 books and 10 journals. Cover pages of these literature were also required

to be submitted. These literature have not been repeated in this thesis.

2.1.0.0 Classification of Related Literature;

The researcher decided on following aspects of Hospital Waste Management, to be

critically analysed by various other authors/researchers;

& Role of WHO/CPCB/MPCB/NMC. World Health Organisation (WHO) is the

apex body to disseminate rules and guidelines in this regards. Role of Ministry of

Environment and Forests (MoEF),Pollution control boards- Central, at Maharashtra

state level and effectiveness of Regional and sub-regional offices at Nashik.

& Generation of solid waste.

& Segregation of medical waste from generic waste, and disposal of sharps

waste.

& Infectious Sharp Treatment

& Pre-treatment of medical waste before disposal

& Waste Minimisation

& Transportation and Storage of hospital waste

& Common treating facility provided by the municipality& Awareness and training

& Technologies available world wide, and in India for treating medical waste.

& Impact of improper bio-medical waste disposal on the community& Efforts taken to improve hospital waste management2.2.0.0 Role of WHO, Ministry of Environment and Forests (MoEF), various

Pollution Control Boards, and Nasik Municipal Corporation (NMC)

WHO initiated this issue in 1998. In 1999, a book Safe Management of Wastes from

Healthcare Establishments was published. This book, said to be bible on the subject,

is official version of WHO, and is co-authored by A Pruss, E Girault, and A

Rushbrook. Almost all countries in the world have extracted their initial statutes on

this subject from this book. The Ministry of Environment and Forests, Government of

India in exercise of powers conferred by sections 6,8,25 of Environment (Protection)

Act 1986 has notified waste (management and handling)rules 1998 on 27 July

1998 (Appendix A). The rules were amended on 6 March 2000, and 2 June

2000.These have been promulgated almost afresh in September 2011(Appendix B).

Latest rules have been aired for public scrutiny before final adoption. The purpose of

these rules is to arrest widespread dissemination of communicable diseases by

managing medical waste. It also mitigates this transmission in handlers of medical

waste. Central Government tries to spread awareness about this thing by various

means. Central Pollution Control Board (CPCB) is central nodal agency co-ordinating

all such issues.

The rules envisage establishing a “Prescribed Authority” for implementation within a

period of one month by the state Government. The Maharashtra Pollution Control

Board (MPCB) has been designated as the Prescribed Authority for implementing

these rules. The following studies elicit the role of MPCB in implementing bio-

medical waste disposal rule. WHO has released second version of their above book in

December 2013.

D’Silva Jeetna (2000) says that the biomedical waste issue is far from over. And thistime it is the authorization aspect that seems to be creating quite a stir. The

biomedical waste rules of 1998, requires the institutions to make an application for

grant of authorization to treat biomedical waste. The bone of contention in this is that

the basis for charging the fee is vague. The fee which is based on the capital

investment or cost of the entire healthcare facility has been branded as unfair by the

medical fraternity. The Tata memorial hospital was till 2004 the only hospital in the

country to have its own effective system, the hydroclave to treat its biomedical waste.

But as the hospital has applied for authorization, it has reportedly been asked to cough

up Rs. 1 lakh termed as fee by MPCB with the assumption that the investment is 1

crore. Many hospitals have therefore decided not to apply for authorization as they

believe that capital investment has no correlation with the potential for waste

generation for example-a super specialty Ophthalmology hospital require a huge

investment while it hardly generates any waste which on the contrary for a unit

specializing in gynecology the converse would probable hold true.

Another reason why the medical community is peeved about the entire issue is that

neither the NMC nor the MPCB is willing to be accountable for the management of

bio-medical waste for small quantity of medical waste generators.

Iyer Malathy (2003) in her article “State Pollution Control Board will warm hospitalsflouting bio-medical waste rules” says that the Maharashtra Pollution Control Board

(MPCB) will issue notices to hospitals and nursing homes that haven’t complied withthe biomedical management rules 1998. A list of defaulters has been already been

drawn. The penalty could be imprisonment and a fine of Rs 1 lakh for not abiding by

the waste disposal rules. The rules require that the biomedical or infectious waste be

segregated from normal waste. It will then be sent to the NMC incinerator at Tapovan

if the hospital does not have an in house facility. According to NMC officials, barely

20 percent of biomedical generators in the city reach its incinerator at Tapovan.

However, the healthcare workers give several reasons for not being able to comply

with biomedical waste management rules as given below :

Some registered generators with MPCB said that NMC appointed

transporter is not able to collect biomedical waste from their

clinics as there aren’t enough clinics in particular area for

contractors’ vehicle to visit everyday. At times waste is notcollected even in 4 days if a Sunday comes in between. The rules

however stipulate that bio-medical waste should be disposed

within 48 hours because of its toxicity.

Jagriti Bhatia of HOPES said that even for the big hospitals

shelling out of Rs 5 – Rs 14 for one bio-degradable plastic bag is

very expensive and there is little to substantiate the claim that

these bags are bio-degradable. Even plastic manufactures are

skeptical about this claim. The need of the hour thus is to rope in

more transporters for biomedical waste.

A medical fair was held at Pragati Maidan New Delhi from 25-26 March 2011. This

showcased all aspects of medical waste management.

At state level, Maharashtra Pollution Control Board (MPCB) has been notified as

“Prescribed Authority” to implement statutes of Central Government in this regards.

Similarly, Regional Office of Pollution Control Board, first floor, Udyog Bhavan,

Nashik is the Prescribed authority at Regional/sub regional jurisdiction.

Annual reports of Maharashtra Pollution control Board, and Regional office of PCB,

Nashik, also elucidate on hospitals/clinics defaulting in regards to registration for

medical waste management. Penalty of Rs one lac and/or imprisonment has been laid

down for not abiding by statutes in this regards. Medical units of all types and sizes

are required to segregate medical waste from generic, and then dispose off. Hardly

20% of medical units are actually abiding by above statute. The monthly/annual waste

collection data at facility at Tapovan is clear example for this.

In Times of India, Nashik Edition,23 April 2012. Mr AS Fulse MPCB Regional

officer in his interview accepted that Nashik is 45th amongst 88 most polluted cities in

India, and 6th in State of Maharashtra.

NEWS(2006) published by Indlaw.com states that Bombay High Court has directed

Maharashtra Pollution Control Board (MPCB) to survey 366 government hospitals in

the states and initiate an action against those who were found violating the bio

medical waste disposal rules and to submit the report by December 2006. The order

was issued by the court on hearing PIL filed by Consumer Welfare Association

complaining that the Government hospitals were not following proper procedure for

disposal of bio-medical waste. An example was cited by petitioners counsel Rajiv

Chavan, that one of the hospitals in Baramati still uses pit burial method for bio

medical waste disposal.

Sub-regional office of MPCB were kind enough to hand over copy of annual report 01

January 2012 to 31 December 2012, submitted in April 2013 to MPCB. This forms

basis of statistics quoted in later chapters and for analysis.

Dr DB Dabolkar, member Secretary, MPCB(Aug 2004) and Mr Rajiv Mittal member

secretary MPCB (Inspection March 2013,Report June 2013)(www.mpcb.gov.in) have

reported on status of some common facilities for collection, treatment, and bio-

medical waste in Maharashtra. This gives details of all aspects in Maharashtra

including Nashik Distt. It says that hospitals do not generally send non-

incinerable/autoclavable waste to the central facility. The waste is sold for re-cycle

without any treatment. This is in violation of rules. It lays down proposed action plan.

8th Quarterly Action Taken Report on 30 October 2005 on directions of Honble

Supreme Courts in r/o WPC No 657 of 1995 date 14 October 2003.As per this In Oct

2004, 100 hospitals were issued show cause notices for non-implementation of

Hospital waste Management (management and handling) 1998. Nasik is least at fault

in various indices in state of Maharashtra, meaning state of affairs are comparatively

better than others.

Nashik Municipal Corporation (NMC) in City Development Plan 2011, and JNNURM

charter have discussed in detail present status of Hospital Waste Management in

Nasik. Separate funds have been earmarked in 12th plan towards bio-medical waste

management. In its projections upto 2016 it plans to spend;

Rs 500 lacs each on study and implementation of segregation at source

Rs 900 lacs on 60 ghanta gadis

Times News Network (2003) published in their article “Biomedical alarm after BMC

shuts Sewri incinerator” that the facility informs that Sewri incinerator, Mumbai was

found to be functioning poorly and polluting the environment. After making some

efforts to repair it, the BMC shut it in October 2003 and is sending all the medical

waste to the dumping grounds. City activists are concerned that highly toxic medical

waste is being sent to dumping grounds without being treated and feel that it is a

matter of grave concern and therefore an alternative way to treat the waste should be

decided immediately.

Kashyap Siddhartha D (2004) in his article “Finally a crackdown on Pune’s biomedical waste” has described the system of disposal of bio-medical waste in Pune.

He says that Pune’s medical fraternity ought to be ashamed of them. Barely 16 of the5000 plus dispensaries, 46 of 2000 odd pathological laboratories and 9 of 20 blood

banks are utilizing the Pune municipal corporation (PMC) bio medical waste (BMW)

disposal facilities. The rest are blatantly dumping their waste in the neighborhood bin

or open spaces. Not surprisingly, the Maharashtra Pollution Control board (MPCB)

has started serving legal notices to 1000 health care establishments in the city for not

complying with hazardous bio-medical waste norms. So dismal is Pune’s record on

this front that the MPCB should have ordered the shutting down of hospitals,

dispensaries and pathology labs which are not following the rules as required the

biomedical waste (Management and handling) Rules 1998. PMC, four years ago

appointed a private operator to treat 3 tones of infectious bio-medical waste generated

daily in the city. However, a majority of the health care establishment till date

continue to lax on following the bio-medical waste guidelines.

Reshma Patil (2005) in her article Biomedical waste-Pollution board raps seven

hospitals says that on Dussera day, seven of Mumbai’s busiest and best knownhospitals got an unexpected warning from the state’s pollution watchdogs through

show-cause notices citing alleged “non-compliance” of bio-medical waste rules. The

summons in 2005 were as follows:

Balabhai Nanavati Hospital, Vile Parle – No shredder and Effluent

Plant

Lilavati Hospital, Bandra – No autoclave, shredder and ETP.

Gokuldas Tejpal Hospital, Fort – No shredder and ETP.

P.D. Hinduja National Hospital and Medical Research Centre,

Mahim – No shredder and ETP.

Camma and Albless Hospital, CST – No shredder and ETP.

Sir JJ Group of Hospitals, Byculla – Segration needs

improvement, no shredder, ETP and leaks in pipe line carrying

effluent.

St. George Hospital, CST – No ETP, segregation not proper.

2.3.0.0 Generation of solid waste, segregation of medical waste from generic

waste;

Basic Document of WHO, as stated in Para above, gives unit wise generation of bio

medical Waste ;

OPD; Bandages, plastics, sharps

Injection Room; solids, sharps, injections

General Ward; solid sharp, soiled waste

Emergency Ward; Sharps, solids, soiled waste

Labs; Placenta, soiled, solid sharps

ICU; Sharps, soiled, solid

Labs; solid, soiled , soiled, cultures

Detail Project report for Solid Waste Mnagement,2006 for Nashik also dealt with

application of all aspects of hospital waste management. Draft City Sanitation Plan for

Nashik from 2012-2052 deals with almost all aspects of hospital waste management in

Nashik in a phased manner.

Nasima Akhter-Environmental Engineering Programme, School of Environment, and

Development(Jan 2000)Asian Institute of Technology,Thailand(www.eng-

consult.com). This deals with generation of waste in many countries in the world.

Air Marshal(retd) Lalji Verma, President of ISHWM, 2006, Book on “Managing

Healthcare Waste” deals with various issues in simple layman language on all issues

pertaining to hospital waste management in India including generation.

2.4.0.0 Segregation;

Segregation of medical waste at sources is the first and main step towards having a

sound waste management programme in any hospital. It helps in ensuring that the

quantity of waste needing special attention is considerably reduced, and is more

manageable and cost effective. Many researches are conducted in this direction and

the findings are as follows.

Participating Research in Asia (1998) conducted a study to assess the means and the

status of hospital waste management in various hospitals in Mumbai and concluded

that segregation of biomedical waste is not carried out properly due to lack of

supervision and monitoring. The infectious and hazardous waste is still dumped into

the general waste. Color coding system for segregation is followed only in hospitals

having more than 50 beds.

NSS Unit of Mithibai College (1999), Mumbai conducted a study in 65 clinics. The

study revealed that 60% of the clinics wrapped their medical waste in plastic bags and

put them in municipality common bins. Looking at this 81% of the doctors felt the

need for proper segregation of medical waste and 57% of the respondents required the

help to set up their segregation facilities. In certain areas, while conducting the

survey, the students observed used syringes and vials scattered all over the place.

Kankhal Ashok Gulab (1999) observed that the government hospitals use plastic and

metal containers for segregation and collection of medical waste but private hospitals

preferred plastic containers. Segregation is not done in organized manner in hospitals

in the Jurisdiction under Municipal Corporation of Greater Mumbai.

P Hanumantha Rao; Report HWM-Awareness and Practices. He has carried out

detailed study in 3 states of Maharashtra,UP, and Andhra. The issue of segregation

practices and status is the main finding of this voluminous study.

Eigenheir Zannon,1991. He has dealt with classification into solid and liquid. This is

as follows;

Solids;-Performing and cutting waste/non performing and non cutting waste.

Liquids; Biological, chemical, over date medicines, and radioactive waste.

Zannon also deals with health hazards associated with medical waste. This is relevant

to the scenario in Kammanwar Bridge, Nashik where medical waste is just stuffed into

least number of coloured bags for incineration.

Kamdar Seema I (2004) in her article “Hospitals are color blind to red and yellowwaste” has clearly explained about the improper segregation of medical waste in red

and yellow bags. It states that the only BMC run centralized bio-medical waste

treatment facility at Sewri treats the infectious waste of around 1500 hospitals and

nursing homes in Mumbai. The numerous problems dogging the issue of bio-medical

waste in Mumbai and in other cities in the state show up all the players such as

hospitals, treatment facilities, the BMC and the Maharashtra Pollution Control Board

(MPCB) in poor state. The problem starts at source where the waste is segregated.

Infectious waste is of two types : anatomical tissues which should be packed in yellow

bags and sent for incineration and other blood stained waste such as plastics cotton,

gaze etc should be packed in red bags and autoclaved. But at Sewri, several yellow

bags go in for autoclaving along with the red ones. The attendant explains since many

hospitals don’t observe the color coding, we assume that the heavier bags containanatomical parts and send them to the incinerator at Taloja while the lighter once go

into the autoclave.

Jatania Prachi (2004) adds and supports the same observations as given by Seema

Kamdar. She highlighted her observations in her article “Hospitals Crisis-Blame game

continues in Mumbai” and describes how segregation of medical waste is done inMumbai hospitals. According to bio-medical waste management rules, the yellow

bags should have discarded limbs, tissues and other potentially infectious anatomical

waste that needs to be incinerated at super hot temperature so that the most virulent

pathogen also can not survive. Now, if one looks inside any of the yellow bags at

Mumbai’s sole medical waste graveyard at Sewri, one will find heaps of syringes andantiseptic bottles mixed in with other incinerable medical waste, which is then

incinerated. The burning of plastic, metal and glass pumps the toxic plume into

Mumbai’s air and clogs the incinerator. The incinerator at Sewri was shut in 2003because incensed residents protested, so yellow bags shouldn’t be here. At the heart ofa medical waste crisis looming over Mumbai is the inability of most of its 700 private

hospitals to segregate the waste. Syringes and bottles should go into a red bag for

autoclaving before shredding. The Sewri plant now only unloads the red bags and

sends the yellow to Taloja on the outskirts of Mumbai.

Chaithra, Bharti and Manjunath (2004) carried out a cross sectional investigation in

Aug & Sep 2004 in Victoria and Vani Vilas hospitals of Bangalore and found the

same poor conditions of hospital waste management in them. They observed that 91

percent healthcare personnel showed poor level of knowledge regarding color code

used for different categories of biomedical waste and their disposal. It was also

observed that basic facilities like color bags, needle burners, puncture proof containers

were missing in few locations and in most of the departments medical waste is not

properly segregated for the next stage.

Kiran, Goud, Joseph, Isaacs and Rodriques (2005) conducted a study to look into the

healthcare management systems in plantation healthcare centres in Karnataka. This

descriptive study covers 30 coffee/tea plantations in Chickmagular, Hassan and

Kadaru districts in south Karnataka having 24 healthcare centres by employing a field

tests observation check list. The study observed that segregation of medical waste

was practiced only in 9/24 (29 percent) centres. Even the color coding scheme and

other components were not uniform.

Air Marshal(retd) Lalji Verma, President of ISHWM, in Journal of ISHWM Vol

9,Issue 1, September 2010 in article “A Study of Hospital Waste Management at a

rural hospital in Maharashtra has very categorically tabulated generation of various

wastes in various ward/OT/OPD of Pravara Hospital. This formed basic of study

during field work of study.

Varkey Peter K, Achari, Jacob and Sivasomkara Pellai (2000) undertook a case study

of biomedical waste status and strategies of treatment in Cochin City. The study

revealed that medical waste generated was segregated at the point of origin itself and

collected into five different colour coded containers. Cochin City needs to create

awareness regarding the hazardous nature of waste among hospital staff and patients.

The study undertaken by Srinivas Chary V. (2002) to know the status of hospital

waste in Bidar City reveals that waste generated in Bidar city was 922kgs/day. Out of

that 53% fall under infectious waste category and 40% of this infectious waste is

amenable to incineration category as per biomedical rules. Healthcare establishments

in Bidar do not have any waste management policy, plan, written operating

procedures, dedicated man power and budget allocation. The waste was collected in

open containers without disinfecting it. Color coding and labeling of containers is not

followed. In 95% of the healthcare facilities medical waste is not segregated. The

glassware and glass IV bottles were not broken.

Times News Network (2002) published that a report titled “Infected Mumbai” of Medwaste Action Group clearly mentioned, that though the central Governments deadline

for hospitals to implement bio-medical waste rules is on December 31, most hospitals

surveyed by the group didn’t even segregate waste into infectious and non infectiouswaste as stipulated by the ministry of environment forests in 1999.

From the above discussions, we conclude that still the rules for segregation are not

adopted by most of the healthcare institutions due to lack of supervision and

monitoring all over our country. Hospital staff is still in an orgy of confusion

regarding color coding of bags for segregation.

2.5.0.0 Infectious Sharp Waste Disposal;

Correct disposal of sharps is important because they form the major threat of risk of

blood borne diseases from biomedical waste. Sharps include syringes and their

attached needles, scalpel blades, sniped piercing parts of catheters, glass vials, used

slides, small pieces of broken glass and any cutting or piercing article.

Following are some of the researches conducted to investigate sharp management

system adopted by hospitals :

Shaikh Parveen (1999) studied the hospital waste management practices adopted in

two hospitals namely KEM hospital (Municipal) and Bombay Hospital (private) in

Mumbai and observed that these hospitals do not have proper sharp disposal systems.

She concluded that unsafe management of bio-medical waste results in transmission

of hepatitis B, and AIDS virus through injuries by needles and syringes and poses the

most serious risks to health. They must be stored in puncture proof containers and

disposed off in such a away that they are not accessible to drug addicts, children and

scavengers. The people who are at utmost risk are nurses, sweepers, ward boys,

Ayahs and auxiliaries.

The Environment Council (1999) undertook a case study of disposable against durable

devices in operating theatre suites. The project was based at operating theatres in two

hospitals in Thames region : the John Radcliffe Hospital Trust in Oxford, and the

Horton General Hospital Trust in Banbury UK. The aim of the study was to identify

opportunities for best practice in resources use and waste management for health care

delivery in UK. The main measure used was the amount and nature (solid, liquid and

gaseous) of the total wastes generated using suction receptacles in operating theatres.

The hospitals were selected because the John Redcliffe currently uses a disposable

system in theatres, while the Horton general employs a durable system. The study

compared the costs of the two systems. Major findings of the study are :

That disposable system had a significantly higher negative impact upon

the environment than durable ones. The impacts include energy

consumption, resource depletion and contribution to environmental

problems such as global warming, acidification and toxicity to humans.

Disposable systems cost significantly more than durable systems in

terms of both purchasing and disposal costs. Disposal costs are

unlikely to fall in the future.

The use of durable products highlighted opportunities for cost and

energy savings as well as reduced environmental impacts through the

use of efficient washing and drying facilities. One hospital managed

almost to halve the comparable costs incurred at another hospital by

using much shorter operating cycles.

One measurement suggested that contrary to the perception of some

managers, the disposal system might in fact pose increased risks. It

showed that 70% of used receptacles were not fully sealed for disposal,

posing an increased potential risk to unqualified staff and the general

public. This highlights the need to carryout further work to quantify

and evaluate the risk potential of both systems in more detail.

NSS Students from MMK College,Mumbai (2000) conducted a survey in

collaboration with clean Bandra Campaign and Mumbai Med Waste Action Group

(MMAG) and found that Only 3 out of 93 healthcare personnel interviewed, disposed

off their needles in puncture proof containers.

Desai Rajani (2001) conducted a study to take the opinion of medical professionals on

the issue of hospital waste management. The survey results indicating the attitude of

doctors towards medical waste was analysed and discussed after considering the

various waste disposal options. It was found that 91% of the doctors believed that the

improper medical waste segregation and disposal is responsible for spread of disease.

It was also noticed that 82% of the doctors use disposable plastic syringes as they

believed that spread of infections can be controlled by using new syringes and needles

for every new patient. 34% of the doctors recapped needles while only 54% of the

doctors understood the importance of needle breaking. The rest 12% of them

accepted and were satisfied with whatever they got.

A correspondent of Focus, Hyderabad Healthcare (2002) highlighted the growing

menace of recycling of bio medical waste in Mumbai. In India about one person dies

every 20 seconds making it a million every year due to the use of contaminated

needles. Further 13 out of the 17 brands of syringes that are being used do not fall

under desired standards. These were a couple of grim statistics highlighted in a study

on hospital waste management conducted by the students of Sophia polytechnic,

Mumbai.

The study further noted that, Mumbai generates about 50,000 kgs of biomedical waste

every day from 1200 hospitals and 15000 nursing homes and clinics. Of this, 90% of

the waste is non infectious while the rest 10% is infectious consisting of IV fluids,

catheters, syringes, scalpels bandages, gloves etc. while hospitals claim to dispose off

their waste as per the stipulated norms, it is shocking to note that much of infectious

waste including needles, syringes, catheters etc, are being recycled only to find its

way back into the market.

The study pin pointed rag pickers as the chief agents behind this menace as they pick

up improperly discarded gloves, syringes, needles, IV fluid bags, catheters and urine

bags from various disposal sites across the city and eventually sell them off to

wholesale dealers, who in turn clean and repackage these items to sell them into the

market once again.

Iyer Malathy (2002) in her article “Toxic jab coming to the hospital near you” hasreported about the way infected disposable syringes are brought back to the market by

some of the people handling infectious sharp waste in the hospital.

A sting operation was carried out following a complaint made by Mumbai med Waste

Action Group, a non government organization. The civic raid has round that the

drivers who were entrusted the work of carting away infectious biomedical waste

from city hospitals, sold syringes and needles to a scrap dealer on route. Inspectors

from the Bombay Municipal Corporation’s vigilance cell caught the driver of one of

the special vans carrying infectious waste on the road to I max theatre, Wadala. The

driver of another van was also caught at the same spot half an hour later.

Bhatia Jagriti an activist of NGO HOPES,Mumbai along with other activists showed

their worry about the larger implications of this illegal practice as it would be great

health hazard if some of the used syringes and needles are washed, and are made to

make their way into clinics.

The additional municipal commissioner Mumbai called a meeting of the Citizens Cell

to oversee the implementation of the biomedical waste and said that they would

submit the report at earliest to Maharashtra Pollution Control Board which is the

controlling authority and the divisional magistrate.

Times News Network (2002) published a report titled “Infected Mumbai”-Med Waste

Action Group clearly mentioned that though the Central Government’s deadline forhospitals to implement bio-medical waste disposal rules is on December 31, most

hospitals surveyed by the group didn’t even segregate waste into infectious and non

infectious waste as stipulated by the ministry of environment forests in 1999.

Chatterjee Sharmistha (2004) in her article “Danger at needle point-Recycled syringes

still a big health hazard” clearly states that there are a family of rag pickers who died

on duty. All of them were infected by the deadly HIV virus while scavenging through

garbage dumps around the hospitals in south Mumbai. They are not only victims of

recycled (disposable plastic) syringes and needles which is increasingly proving to be

a major health hazard. This is validated by the rise in HIV, Hepatitis B and C

infections in Mumbai.

Anurupa MS, Suryakant, and Vijay Kumar (2005) in their study have investigated the

practices adopted for hospital waste management in Davangere, Karnataka.The study

included 182 allopathic health care setups of Davangere City. The heads of the setups

were visited and then they were interrogated to obtain the data. Among 182 health

care setups 3 were teaching hospitals, 29 were private nursing homes, 120 were

general practitioners clinic, 30 were dental setups. The quantity of the waste

generated varied from 7gms to 1.4kgs/patients/day. Large quantity of waste was

produced by nursing homes and less by dental setups. Major type of the waste is

contributed by general waste followed by human anatomical waste (361

gm/patient/day).

Appropriate management of syringes was observed only in teaching hospitals.

Disfigurement of waste sharps was practiced in only 53% of the setups. 70% of the

hospitals disposed their sharps waste into the public dustbin, 44% health care setups

were selling recyclable items without pretreatment and disfigurement. The liquid

waste was disposed directly into the underground sewage system without pre

treatment.

The studies reveal that even after issuance of bio-medical waste (management

&handling) rules of 1998, healthcare institutes do not adhere to the established norms

regarding disposal of sharps. The studies also indicate that disposable articles have

significantly higher negative impact upon environment than the durable ones if not

handled efficiently. The studies also show that used disposable syringes and needles

are marketed by people handling infectious waste and are reused by small health care

centres particularly in rural areas.

2 .6.0.0 Pre-treatment of Medical Waste before Disposal;

Another important step to be followed for appropriate hospital waste disposal system

is the pretreatment of medical waste before disposal. The chemical disinfection prior

to disposal is required for sharps, disposable infectious plastics, rubber, infectious

glass wares, blood, body fluids and linen stained with blood. Very few studies are

undertaken in this aspect of hospital waste management and their observations are

given in subsequent paras.

Kankhal Ashok Gulab (1999) found that 50% of the municipal and government

hospitals disinfect their medical waste before disposal with formalin or Hypochlorite.

The sharps are disinfected only in some cases. Cultures and pathology samples are

not disinfected before disposal even in large hospitals.

Dola Sanjay Kumar (2001) studied the medical waste disposal practices in Rajawadi

Hospital, Mumbai and found that the sharps are treated with 2 percent hypochlorite

solution and then sent for incineration as per rules.

Srinivas Chary V. (2002) of Center for Energy, environment and Technology,

Hyderabad revealed the fact that the biomedical waste was collected in open

containers without disinfecting it. Even linen with infectious body fluids is washed

without prior disinfection.

Kiran,Goud,Josephs,Issacs, and Rodrigues,2005 observed that only sharp waste was

disinfected before disposal in Karnataka.

Ayushman Ratna Singh Shikha, Megha, and Ravi Agrawal (2002) conducted medical

waste incinerator survey in Delhi hospitals. The survey covered 16 hospitals that had

onsite incinerators. There were 29 incinerators total. This number had declined from

51 in 2000. It can therefore be concluded that;-

1. Centralised services were accepted

2. Involvement of high cost of running incinerators. A hospital spends about Rs

2,69,000 and Rs 55000 annually on diesel and manpower respectively.

3. Awareness in communities regarding dangers associated with incinerators.

From the above observations and findings of related studies conducted in this field,

we can conclude that even fifteen years after issuance of bio-medical waste

management rules, majority of the hospitals do not segregate and disinfect their

biomedical waste as per bio-medical rules 1998 and therefore lots of attention is

required in this field.

2.7.0.0. Waste Minimisation;

Waste Minimization is the best way to reduce biomedical waste costs and reduce

environmental impact on air pollution and landfill capacity. Effective minimization

requires that all purchases and supplies be made with waste reduction in mind. This

can lead to the purchase of re-usable or recyclable instead of disposable in some cases.

Use of plastics and disposable articles should be limited due to illegal recycling and

reuse.

The Environment Council (1996) under took a case study of the Pembroke shire NHS

Trust which implemented a system to reduce amounts of clinical waste it produced.

The system operated as follows :

The numbers of black and yellow bags used were monitored.

Targets were set to reduce the proportion of yellow clinical waste bags

to black household waste bags.

Cardboard was dealt with separately from the rest of the waste stream.

Each ward was visited to check that the correct options were provided

whenever possible.

Information on the differing costs of clinical and household waste

disposal was posted above disposal points in an effort to raise awareness

of the purpose of the exercise.

Continual monitoring of the wards was done. The wards were revisited

at regular intervals to check compliance with the new

arrangements. Statistics were kept to evaluate the effects of the polity.

The system allowed infringements to be reported to the senior managers.

Statistics from this system showed that total waste production remained the same.

Despite this, significantly more waste was placed in the black bags and less in the

yellow bags over a six month period. Monitoring has shown a sustained change.

Lal Neeraj (1999-2001) investigated management of biomedical waste in a tertiary

care hospital in New Delhi. The objectives of the study were :

To minimise the hospital generated waste from sources to an

acceptable limit.

To find out various recycling procedures.

To reduce the overall health risks to patients, workers, public and

damage to the environment.

To recommend an effective waste management program.

The study was conducted in 3 private hospitals of New Delhi and data was collected

by taking informal interview of the respondents and personal visit to various

departments in the hospitals. Some secondary data was also used for the purpose and

the conclusions drawn from the study are as follows. The volume of waste in a

hospital is increased due to regular use of disposable items mainly because of :

Increased public awareness about infectious disease.

In attempt to improve quality of hospital services.

Increased public awareness about consumer protection act.

Hence minimization of the waste is important step in medical waste management.

The practice of 3 R’S namely Reuse, recycle and Reduce is suggested by the

researcher. Vermi –Composting as method of disposal is also recommended by the

investigator.

Times News Network (2002) published that the Bombay Municipal

Corporation(BMC) high transportation charges of Rs 18 per kg came in for criticism

at the meet . Dr R Bhalerao of Mumbai Hospital infection Association said that rough

calculations done by Hunduja Hospital found that the cost of transporting the waste

from the patient’s bed to the incinerator should not be more than /rs 8 per kilo. He

added that the high cost had deterred many hospitals from subscribing to the common

waste treating facility.

Dr Bhalerao also pointed out that rather than grapping with increasing loads of waste,

the focus should be on reducing the waste. All that can be reused should be reused

such as syringes can be used while needles need to be disposed. He also suggested

that cutting down on the use of plastics is more environmental approach.

EH Rau (2000) in an article on Minimisation and management of waste from hospials

in Environ Health Perspective 2000 Dec,108 (suppl 6) says that minimisation relates

to volume and toxicity.

In Philipines Extended Producer Responsibility (EPR) is compulsory. The

service/equipment provider is responsible for sale, collection after use, reuse/recycle.

This is novel idea.

As per this researcher minimisation is the most important issue in this gamut of

hospital waste management. Therefore much literature was researched and an article

written in International magazine CENTUM-August 2013, under aegis of prestigious

JJT University.

2.8.0.0. Transportation and Storage of Biomedical waste;

Kulkarni Saurabh (Nov 2011) has talked about service corridors in hospitals to carry

waste up to last bin and collection area. Though novel concept, we understand that at

least no private hospitals are likely to earmark specific alleys for this purpose for cost

aspect.

RK Khwaza, MOEF, New Delhi (Mar 2010), Report of Committee to Evolve Road

Map on Management of Waste in India has propounded clearly identifiable

transportation bins for use in hospitals.

In ‘Performance audit Report on management of Waste in India’ report by CAG,

Acharya DB has enunciated three precautions for transportation, viz;

Direct contact with medical waste should be avoided.

Bags should not be overfilled and emptied into other bags.

Transportation must only be done in authorized vehicles.

NEERI Study on MSW in 3 cities of Maharashtra, viz Nashik, Pune, Nagpur was

conducted in 2004. It opined that many vehicles were used for transportation of MSW.

In case where transportation distances were large, transfer was done from smaller

vehicles to larger vehicles enroute. However, since this was not done under

supervision it left room for improvement.

2.9.0.0 Common Treating Facility provided by Municipality :

As it is difficult for every hospital to have individual medical waste treating facility,

the Pollution Control Board thus has directed the local municipal bodies to provide

common medical waste treating facility for disinfection of medical waste generated by

the hospitals of their towns. The facts related to this aspect of medical waste

management revealed by various studies are as given below :

NSS Unit of Mithibai College, Mumbai (1999) conducted a study in 65 clinics and

revealed that 97% of the clinics continue to dump their infectious waste into BMC

bins and one of the pathological labs disposed its waste into the sea. Waste from 67%

of the clinics was being collected on daily basis. 14% of them said that this medical

was being spread out on the roads by stray animals and cattle and therefore 59% of the

respondents showed their willingness to join common medical waste disposal

scheme. 83% of them were not willing to invest in the waste treating and disposal

technologies like incinerator, microwave, autoclave or hydroclave individually.

Nair VS (1999) the technical consultant Indian medical association, carried out a

study to assess the total biomedical wastes produced in the Kollam Disrict undertaken

by the European Commission Sector Investment Program, the District Health and

Family Welfare Agency. A survey of the Kollam district was done and the present

census of the hospitals and clinics was made. Health care facilities were selected

which were two in urban areas, one in rural area, one governmental hospital and one

dental clinic.

The waste generated in each of these health care facilities was studied and data

collected. It was observed that the average biomedical waste generated per bed per

day is 180 gms. The dental clinics produced 650 grams of infectious waste per day. It

was noted, that there was an increase of 55% in the total number of beds, out of which

30% increase was in government hospitals, 66% increase in private sector and 85

private clinics had no beds.

The researcher found that 2000 kgs of infectious waste was generated by health care

facilities of Kollam district everyday and therefore, a properly planned project for the

management and disposal of hazardous waste should be implemented and carried out

at the earliest. Individual waste facilities were not possible due to the high cost and

environmental problems. Establishment of a common waste treatment facility in the

district was strongly recommended. The waste to be incinerated as per bio-medical

waste management rules was about 1600 kgs per day while the balance 400 kgs was to

be autoclaved and shredded before disposal.

Krishna Kumar (2003) in his article “Hospitals and relatives to dispose of limbs”

clearly shows that private hospitals in Mumbai are asking shocked family members to

dispose the amputated limbs of patients as they have no arrangements for doing so.

Doctors in these hospitals said that they are forced to make the move as the private

contractor appointed by the BMC for collecting biomedical waste is irregular and in

some cases collected the waste only once a month.

In fact a similar situation has cropped up at Bhagwati Hospital in September last year

when authorities asked a women to dispose off her brothers amputated foot but later

on the leg was disposed by the hospital itself. In Thane on January 18, 2001 a 20

years old boy was handed over his diabetic mother’s amputated leg which was buriedwithin the crematorium.

Deepa A (2003) in her article, “BMC lax in picking up biomedical waste”, clearly

states that according to the Additional Municipal Commissioner BMC has been

receiving complaints from doctors about the medical waste not being collected and

also gave assurance to the doctors the BMC has asked their private agency to increase

the number of trips to facilitate better collection of bio medical waste. Deepa A has

cited very interesting cases in this article :

Dr. – Mayank Chitra doesn’t like disposing off the biomedical wastefrom his nursing home into the municipal bins as it is illegal. He is

clearly aware of health hazards posed to the community by the

disposal of infectious waste in such a manner but doesn’t have muchof choice as Brihan-mumbai Municipal Corporation (BMC) hasn’tbeen regularly picking up infectious waste from his nursing home

leaving him with no alternative but to dump it into the public dustbin.

His complaints to the BMC didn’t work instead and the corporation

penalized him Rs 2000/- for not complying with biomedical waste

(handling & management) rules, 1998.

Dr Lalit Kapoor of Association of Medical Consultants explained

that they have a contract with the BMC and pay them Rs 18/- for

picking up one kilo of biomedical waste and taking it to burn it in

Sewri incinerator. Though the BMC and doctors signed such an

agreement the corporations pick up vans have almost never made an

appearance.

Dr Ketan Parikh who runs a nursing home in Ghatkopar said that

though the doctors have paid a deposit for transporting the

biomedical waste, the Civic Corporation hasn’t kept it to its side of

the agreement and therefore doctors end up throwing biomedical

waste into municipal bins.

Times News Network (2003) also published an article “Dumped human limbs cause a

scare” states that rag pickers scrounging for metal at Mulund dumping ground

stumbled upon human limbs. Some civic officials said that biomedical waste was

initially being disposed off at the Deonar dumping ground but due to protests by local

political activist, the BMC started using Mulund dumping ground without informing

and inviting objections from the citizens before taking a decision to use the Mulund

ground for this purpose.

Later in the day municipal commissioner KC Srivastava announced that the BMC

would stop burying body parts at Mulund dumping grounds and the waste would be

now dumped at Deonar until the incinerator is repaired.

Times News Network (2004) published an article, “BMC washes its hands of privatehospital waste,” stating that the issue of management of hospital waste is all set toraise a stink in the coming months as from 1st October, the civic administration has

decided to collect bio-medical waste (body parts, contaminated blood and bandages)

from public hospitals while private hospitals were supposed to make their own

arrangements.

BMC wanted to change the decision because of wide spread criticism of services

given a choice of either using facilities rendered by BMC or those outside the city.

Anurupa MS, Suryakant, and Vijay Kumar (2005) revealed that all the teaching

hospitals and nursing home authorities felt the need for common incinerator for city.

Dentists and general practitioners expressed the need of setting up of common private

organization for disposal of hospital waste. Lack of common setup for disposal, cost

factor, disposal of anatomical waste, non co-operation from the patients attendants

non co-operation from the staff were the problems faced by the heads of the health

care set ups in the management of waste. Complete mismanagement of hospital waste

was observed in healthcare setups of Davangere City. The studies reveal that majority

of the hospital administrators show their concern regarding safe disposal of their

biomedical waste and were willing to pay for the services but felt helpless as

municipality extends no such services to small health care establishments and some

areas of Mumbai.

Prasad KV (2007) found that for over a year according to the sources involved in the

disposal program, the common facility at Orattukuppai on the city’s outskirts burns in

the bio-medical waste from private hospitals in an incinerator or buries in a deep pit in

Coimbatore, and Sathyamangalam (Erode district), but the government hospitals are

yet to join the program for centralized disposal. It is also learnt that the government

hospitals though are willing to join the program, but they are yet to government

clearance for the charges they have to pay.

2.10.0.0 Awareness and Training

From literature perused of various studies in India, it became clear that awareness

levels were abysmally low. Poor education of handlers/ public at large; finances,

priority of hospital waste management vis- a-vis other similar issues relating to

environment were main reasons of poor awareness. Cleaning of Godavari ghats,

availability and cleanliess of drinking water had more importance in Nasik than

pollution of environment by central treatment facility at Tapovan. Efforts were

accordingly directed in higher priority areas.

“Paryavaran Sevak” and “Runambandh” both in Marathi are magazines for

environmental awareness prepared by MPCB. For this MPCB got Environment

Leadership Award by US-ASIA Environment Partnership. However, it is well

appreciated how much will be circulation of such magazines when they are not

available off the shelf on railway stations /book shops.

Central Pollution Control Board runs workshop for managing hazardous chemicals.

Public Citizens Charter has been made for Management of MSW.

MPCB has issued an exhaustive training manual in 2009. This Training Manual on

Bio Medical Waste Management has been prepared by Regional Centre For Urban

and Environment Studies (RCUES) and All India Institute of Local Self Government

(AIILSG), Mumbai. The manual consists of all aspects of management and handling

of hospital waste management. It also includes all statutes issued by Ministry of

Environment and Forests on this subject.

This researcher has also suggested integrated training of various stake holders in

Nasik in his article submitted to Shri Jhabarmal Tibrewala University, Jhunjunu,

Rajasthan. This article is available separately with researcher.

A film has been made by Government medical college Jammu, along with Messers

Medicom Networks, New Delhi. The name of this training film is ‘Future Begins

With Us”. It was released by the then minister of Environment and Forests, Mr A Raja

on 06 January 2006.

Dr Razia Sultana, Project Director Envirinment Protection Training and Research

Institute(EPTRI), Hyderabad,2009. In this document all aspects of training have been

dealt with in the form of self learning document for drivers, superintendent,

administrators. This has been in support from World Health Organisation(WHO).

Another central government initiative is Environment Protection Training and

Research Institute. It imparts training on all aspects of medical waste management.

Dr Syed Abu Jafar Md Musa, DPM(training)DGHS, Mohakhali, Dhaka. The author

talks about investing in training by all agencies involved in medical waste

management.

2.11.0.0 Technologies.

John Docherty, Messers P&O Industrial Ltd United Kingdom posted an email to this

researcher on 7 May 2013 about technology which they recommend. This is being

discussed in detail as it is latest but simple and cheap. They have manufactured

equipment which converts hazardous waste where it is produced into inert waste

which has been completely sterilized. The processed materials can either be disposed

of as a safe waste or has an added value as a processed high calorific RDF (refuse

derived fuel).The equipment has been installed in nearly 400 hospital and healthcare

facilities worldwide.

Law in regards to hazardous waste disposal is changing faster worldwide and is

focusing on distance reduction between the production and the disposal place in order

to limit the risk of infection and epidemic disease during transportation phase.

Therefore, the CONVERTA is born from the idea to transform the waste into a

product, free of risks, stable and dry, usable as fuel to produce energy in various

installations. The CONVERTA equipment changes the waste into a reusable material

by transforming a reject into a stable product, which can be stored for a long time,

transported when a sufficiently viable quantity is obtained to justify the transportation

towards its next use. CONVERTA is a machine born from the idea to transform

medical waste into a product homogeneously grinded, dried and sterilized. The final

product is considered sterilized municipal waste or RDF, and can be stored for a long

time, or it can be used as combustible material to produce energy. The advantage

of CONVERTA is that, in comparison with all other similar equipment, it does not

use an external heat source, but it will generate heat directly inside the waste by

transforming the mechanical energy of the rotor while grinding the waste into thermal

energy. Using this method there is no need to inject pressure or steam from an

external source. Medical waste is treated by a thermal treatment cycle that includes:

waste grinding, evaporation of all contained liquids, heating to the 151 °C sterilization

temperature and holding time of 2 to 3 minutes by continuous dosage of water,

cooling down and unloading of the dry treated material.

The conversion cycle consists of several sequential steps or phases. The waste is first

ground and pulverized to an unrecognisable mixture by a combination of fixed and

actuated hardened steel blades. The heat generated by frictional forces of the grinding

phase turns the moisture into steam. The exact temperature required to pasteurize,

around 104ºc and in the subsequent phase to sterilize is 151ºC, is maintained for a

time that allows for an 18 log 10 reduction in micro-organisms. In order to eliminate

the required amount of micro-organisms required by government regulations, a

complete saturation of waste matter with super heated steam is required for a

minimum amount of time, also regulated by environmental agencies. The

modern CONVERTA achieves saturation within 10–15 minutes due to the high

degree of pulverization preceding the sterilization phase. The machine will handle

inorganics, i.e. reducing the volume not the weight and has no calorific value, but

with medical waste the sharps will be sterile and recovered at the end of the process as

they have a high value. Household waste that is not sorted, the machine will process

tins, drink cans, plastic containers etc, the metal contents can be removed after

processing but the plastic will remain as this adds calorific value to the RDF.

During expert committee of Central Pollution Control Board at New Delhi on 07 July

2011 Mr Timothy Spencer of Positive Impact Waste Solution Texas recommended

PIWS-3000- a technology involving shredding followed by chemical disinfection

using calcium Hydroxide. This technology has been given go ahead for one year

licencing in India.

Bondtech Corporation has propagated case of composite autoclaves. The company

claims to be world leader in it.

Landfill factory

Microwave Thermal treatment

Steam sterlisation

Electropyrolysis.

Glen Macrae in “Basic overview of Developing countries-Medical Waste Treatment,

strategy, and technology has suggested three new non burn technologies;-

Chemicals

High heat technologies-plasma torch, pyrolysis

Low heat ( Autoclaving, microwave, hydroclave)

California Department of Public health has released list of approved technologies for

incinerating medical waste. This is applicable from 07 July

2012.(www.cdph.ca.goc/certlic/medical).

Shila Khan Nishat in MSW, Fuzzy AHP (19 January 2012) has recommended fuzzy

analytic hierarchy process.

There are many advanced technologies available world wide and in India but cost

aspect over weighs utility aspect. The shelf life of most autoclaves used, including the

one at Nasik, has been out lived but old machines continue to function.

Eye Park’s article (1992) “Hospitals bio medical burning making people sick” writtenby a former senior government official and lobbyist at queen’s park gives informationprovided by different reports regarding health care waste in Ontario.

The report prepared for the recycling Council, Ontario states that all 100 existing bio-

medical waste incinerators at Ontario Hospitals should be shut down because they

pose health risk. The other report called “Health care wars in Ontario” stated the

environmental and health effects of these emissions are compounded by the location

of the hospital incinerators existing in the midst of residential area that the hospitals

exist to serve.

The health problem arises, not so much because hospitals burn human tissues, organs

and body parts but because they also burn disposable plastic products in hospital

incinerators. The result is that air near some hospitals in Ontario is a toxic soup of

poisonous dioxins, furans and heavy metals such as lead, cadmium and mercury.

Only one out of 100 hospitals incinerators in Ontario has emission controls.

According to the report lead, cadmium and mercury at 100 levels can result in damage

to kidney, liver and the nervous system. Lead is particularly toxic to infants and

young children.

The chlorine, which forms 58% of the weight of PVC (polyvinyl chlorine) plastics

becomes hydrochloric acid when plastic is burnt. This acid contributes to acid rain

and is very irritating to eyes, skin and muscles membranes and at high concentration

levels can damage lungs.

Dioxins and furans emitted pose a major health risk if incinerators are not operated at

ideal required conditions. It was observed that the condition of 100 Ontario’shospitals is far from ideal. A 1985 Ontario Government study estimated that more

than 62% incinerators were not capable of handling the various components of the

current bio medical waste stream as well as not meeting air emission standards set by

the Ministry of the environment. After five years another study conducted by the

ministry of environment found that levels of metals, dioxins, furans and hydrogen

chloride at almost all hospital incinerators tested by the ministry were higher than

those measured at large, well designed and well operated municipal incinerators.

In spite of severe lobbies against incinerators Ontario hospitals continue incinerating

facilities that aren’t equipped to handle the waste. The reasons being high disposalcost of the waste forces cash strapped hospitals to burn these waste in their old

incinerators. 60% of the waste is exported at a cost of $ 3000 per ton to the city of

Gatineau, Quebec (near) Ottawa, and to Ohio where state of the art incinerators are

used. Ironically, hospitals, who’s job is to help cure illness, may be making people

sick because the Ontario government does not give them money to properly dispose

off their bio medical waste.

In spite of complaints from people, who live beside polluting hospital incinerators,

regarding toxic emissions with bad smell, no heed is paid to the complaints due to

shortage of inspectors hence the major problem seems to be lack of money.

One of the solutions to this problem is to create regional disposal centre who can

afford to use state of the art technologies. Even new technologies such as microwave

can be used. Another technology which is developed in California, compresses the

waste to 20% of its former volume and sterilizes it with steam.

Chaturvedi Bharti, Agarwal Ravi (1996) conducted a study to investigate into the

system adopted for disposal of medical waste in Government and private hospitals,

nursing homes and clinics having less than 50 beds in the city of Delhi.

The survey categorised hospitals into the category of hospitals with incinerators and

without incinerators since the presence or absence of this technology determines the

pattern of waste management in a hospital.

The study revealed that the hospitals and clinics which were not using incinerators,

were disposing off their medical waste by dumping it directly at landfills, passing the

buck to contractors, backyard dumping and dumping in a near by municipal bin from

where ‘kabaris’ take the recyclable items.

In the hospitals and clinics which were using incinerator plastics, glass, cardboard

were manually sorted out from the trolleys of medical waste on incinerator site. The

waste lies in open before it is incinerated and frequently animals such as cows and rag

pickers are seen on the site. Hospital workers segregates infected recyclable manually

in an enclosed yard. In most of the hospitals, plastics are not segregated and are burnt

in the incinerator.

Other general problems of incinerators in Delhi are as follows :

Most hospitals in Delhi were found to be operating incinerators at 400

to 500ºC as against 1000 ±50ºC recommended by central pollution

control board.

The ash generated is thrown into nearby municipality bins instead of

secured landfills.

Discharges from the stack are not monitored thus allowing the

incinerators to become a source of a air pollution.

When an incinerator is installed, garbage to be fed into it remains at the

site and accumulates at one spot in case of any break down or slow

working.

Only 10% to 25% of the medical waste is fed into the incinerator and

the

into

remaining infected waste usually lands up in municipal bins and finally

landfills.

The illegal recycling of waste continues to exist in every hospital

surveyed despite the presence of an incinerator.

Absence of proper segregation leads to incineration of the type of

medical

waste which after incineration increases the toxicity of the emissions

generated from the incinerators

The study not only examined how recycling takes place in Delhi hospitals but also

determined the way in which the waste that is not recycled, comes in contact with

human beings and spread diseases when rag pickers rummage through it.

Fernandes Mitiz (1999) carried out a study by collecting cotton and gauze bandages

from 2 hospitals in Mumbai city. The main objectives of the study were :

To study the medical textile waste generated in the hospitals.

To chemically modify the cellulose fibers, and convert into a useful

product such as absorbent fibres.

To evaluate the product based on absorbency tests.

To suggest use for this product.

The cotton and gauze bandages soiled and stained with blood, pus and medicines were

treated for removal of stains by washing them in water and boiling in soap solution.

The matter was then autoclaved in a strain sterilizer and then tested for sterility.

The material was then scoured rid of the yellow tinge and treated by using different

concentrations of sodium hydroxide (10% to 20%) acryl amide (10% to 20%) which

increased the absorbency of the material in water and saline solution.

This was used to prepare the utility product like gauze pad which when compared

with the gauze paid made solely of conventional material showed higher water and

saline absorbency.

Tomar Shipha (2000) a Delhi based NGO conducted survey reports from time to time.

Srishti conducted surveys with CPCB (Central Pollution Control Board) which

basically focused on incinerators installed in hospitals. This study was undertaken

with the objective to find the actual scenario of waste management in the hospital in

Delhi after Supreme Court ruling of May 1996. Eight major hospitals were surveyed.

The major findings were:

In the hospitals with incinerators, only 14.2% of the incinerators were

operating at temperature prescribed by CPCB.

The waste disposal was carried out by a private contractor in 50% of

the hospitals.

33.3% of the hospital incinerators were operated by the contractors.

Most of the incinerator operators and waste collectors were unaware

of the health hazards of waste they were handling.

Protective clothing were not used while handling the medical waste.

A lot of infectious waste was being directed towards municipal bins

even in hospitals with incinerators.

Independent surveys by two NGO’s Shristi and Vataram and CPCB’sinspection team in Delhi revealed that out of 34 major hospitals in the

city, 11 had incinerators, which were operated at 400ºC– 500ºC as

against 1200ºC prescribed by CPCB for proper destruction pathogens.

Specially designed pollution control devices retrofitted with

incinerators for achieving minimized emission levels and shredding all

the waste sharps prior to incinerator are the standards which are not

followed by the hospitals

NSS unit of St Xavier’s College, Mumbai (2000) conducted a sample survey on thenature and extent of use of incinerators in 8 hospitals of Mumbai city. The purpose of

this survey was to investigate the nature and extent of use of incinerators as a means

for the management of medical waste.

Out of 8 hospitals, incinerators were functioning only in 7 of the hospitals. The 8th

hospital had just installed a new incinerator. The survey was conducted through the

use of close ended interview schedules.

Incinerator ash samples were collected from two hospitals sites in Mumbai. Samples

were then analyzed by the Environment Impact Assessment units of the Bombay

Natural History Society. The survey revealed that a majority of the working

incinerators in the city do not comply with the bio-medical waste rules. Moreover, the

high incidence of lead, a highly toxic substance, in the incinerators ash sample of two

hospitals, shows the poor state of monitoring the incinerator in the city.

Tomar Shipha, Goel Anu (2000), released another survey report of hospital waste

management. The NGO found that though hospitals were aware of the rules and

regulations but were still going ahead with some disturbing actions.

Many hospitals were burning plastics. Shristi found that in some

hospitals, the entire plastic waste was incinerated which is violation of

the rule.

Some of the hospitals were using red bags for incineration while the

rules specify yellow bags; Red bags have cadmium dyes, which are

harmful when burnt.

Incineration ash was being collected by workers without any

protective gear and was being dumped with general waste. The rules

specify that incinerator ash should be disposed of in secured landfills.

Installation of incinerators with in the city limits was banned in other

cities of India but Delhi has incinerators very close to residential

areas.

Many hospitals wanted common waste treatment facilities as they

could not set up individual disposal facilities.

Sabhapathy AK (2002) in his article “Waste treatment facility poses heavy financialburden”, highlighted that though the biomedical (management and handling) rules

came into force in 1998 and were amended in Jun 2000, there are a lot of hassles

before the new rules could be implemented successfully. For instance, government

hospitals are unable to comply with provision of the bio-medical rules due to financial

problems. Besides, hospitals with more than 200 beds were asked to provide facility

for biomedical waste treatment by Dec 31, 2000.

But it is not possible to close down the hospital on the ground of non-compliance of

the rules, since hospitals are rendering essential services to the people. The main

problem faced by the government hospitals is the absence of separate funds allocated

in the budget for providing facilities for biomedical treatment. The following table

shows expenses incurred on individual or common facility by the hospitals.

Table 2.1; Approximate Expenses Incurred on Individual or Common Facility

by the Hospitals.(2006)

Individual Facility Common Facility

Beds Cost of Equipment Monthly Expenses Initial Payments Monthly

Expenses

10 Rs. 7 Lakh Rs. 6,000 Rs. 9,000 Rs. 1,200

25 Rs. 7 Lakh Rs. 5,000 Rs. 22,000 Rs. 3,000

50 Rs. 11 Lakh Rs. 10,000 Rs. 45,000 Rs. 6,000

100 Rs. 14 Lakh Rs. 20,000 Rs. 90,000 Rs. 12,000

200 Rs. 21 Lakh Rs. 30,000 Rs. 1,80,000 Rs. 25,000

500 Rs 30 Lakh Rs. 60,000 Rs. 4,50,000 Rs. 55,000

Courtesy – image

The table clearly indicates the advantage of common facility.

The government sector hospitals are the major generators of biomedical waste

followed by private institutions. As a first step, waste disposal facilities must be

provided in teaching institutions, general and district hospitals. As per the

amendments in Jun 2000, Municipal boards or urban local bodies, as the case may be,

shall be responsible for providing suitable common disposal / incinerator sites for the

biomedical waste generated in the area under their jurisdiction. In case of area outside

the jurisdiction of any municipal body, it shall be the responsibility of the body

generating biomedical waste, Operators of a biomedical waste treatment facility to

arrange for suitable sites individually or in association, so as to comply with the

provision of these rules.

Vijay K (2002) informed, that the Karnataka State Pollution Control Board (KSPCB)

has issued orders restricting the use of incinerators by individual health care units in

the city limits of six city municipal corporations and also in all district head quarters

of Karnataka state. The orders are issued to view installations of some poor quality

incinerators in health care establishments as a part of their treatment facility at their

premises resulting in air pollution.

Upendra Tripathy, chairperson of the board said that they issue first notices, show

case notices followed by notices of proposed directions as per section 5 of

Environment (Protection) Act 1986 to bring the non-complying healthcare

establishment under the network of biomedical waste (management & handling) rules

1998.

First notice issued against an erring hospital is just a reminder issued by the board if

they find that the hospital’s license has expired. Show cause notice is issued later ifthey find that the hospital is still violating required norms despite issuing first notices.

Times News Network (2002) stated that Mumbai Med Waste Action Group reviewed

functioning of eight city hospitals and the civic corporation’s common facility atSewri.

Deepika D’souza of the group said that incinerators are being increasingly recognized

across the world as a source of pollution. Incineration of medical waste like plastic

bags, syringes release toxic carcinogenic dioxins into the atmosphere. City hospitals

that have their own incinerators include St George hospital, Cama & Albless Hospital,

GT Hospital, JJ Hospital INHS Asvini Hospital, Hinduja Hospital, Lilavati Hospital

and Nanavati Hospital.

None of the city’s incinerators including BMC’s centralized facility comply with the

rules said Shweta Narayan who compiled the report. According to the environmental

rules stacks of incinerators must have a height of 30 meters but this rarely happens in

reality. In India most of the incinerators merely burn the waste and those too

releasing toxics into the air. She added that although none of the hospital incinerators

have been working for the past few months, the load at the common Sewri facility was

much below the level that should be generated by the city with 40,000 hospital beds

and medical waste in that proportion does not reach the common treatment facility.

Most of the individual hospital incinerators are out of order and therefore the question

which arises in our mind is that where is this medical waste dumped?

Ayushman, Ratna Singh, Shikha, Megha and Ravi Agarwal (2002) conducted the

medical waste incinerator survey in Delhi hospitals. The survey covered sixteen

hospitals that have onsite incinerators (5 other hospitals with incinerators were not

covered). These hospitals have 29 incinerators. This showed a marked decline in

number of incinerators, as compared to 51 that operated in 2000.

This can be attributed to :

The wider acceptance of the centralized facilities which have

improved their services.

The high cost of running and maintaining onsite incinerators. As per

the survey a hospital spends Rs. 2,69,0000/- and Rs 55,000/- annually

on diesel and man power respectively.

Awareness o community regarding the dangers associated with

incinerators.

The study revealed that :

The data on temperature of incinerators logged as 105ºC in the

logbook was doubtful.

On an average most of the hospitals operated incinerators during

afternoon for 4 hours a day.

Most of the hospitals did not have pollution control devices nor could

provide information regarding frequency of emission testing.

Glass vials, pieces of glass, burnt tubes were found in the incinerator

ash, Gloves, syringes were found lying around in the open at the

incinerator side.

Awareness levels in terms of safety for the workers has increased

since last survey, most of the times waste is fed into the incineration

by hand though some incinerator operators have been provided with

safety gear such as gloves and face masks.

Srinivas Chary V (2002) of Centre for Energy, environment and Technology,

Hyderabad studied the Medical waste management Practices and strategies for safe

disposal.

This research study was undertaken to know the status of the existing waste

management in the city of Bidar and an attempt was made to identify an appropriate

strategy for safe (hygienically and environmentally) management of this waste. A

detailed survey was carried out.

It was then concluded, that combination of technologies should be used for disposal of

medical waste. As individual onsite treatment would be financially unaffordable, a

common treatment and disposal facility (CTDF) located away from the city should be

made available to health care facilities.

Considering the nature and quantities of waste generated in Bidar, a combination of

incineration and autoclaving including shredding facility was thus proposed, and a

proper waste management scheme was recommended for Bidar.

Chitnis V, chitins, DS Patil S, Chitnis S (2002) in their article “Hypochlorite is

inefficient in decontaminating blood containing hypodemic needles” explained the

efficacy of hypochlorite for decontamination of needles.

Infectious biomedical waste and sharps have a potential hazard of transmission of

pathogens. Among sharps, used needles form a major share and their disinfections by

1% hypochlorite are recommended in biomedical waste management rules of India.

The aim of the present study was to evaluate the efficacy of hypochlorite for the

decontamination of needles.

Needles (16g) filled with suspensions of standard strains and clinical isolates of gram

positive and gram negative bacteria in plain normal saline and in human blood

containing anticoagulant were exposed to 1% hypochlorite and the surviving bacteria

were subjected to viable counts.

The observations indicated that 85-90% of needles filled with bacterial suspensions in

saline are disinfected to a level of 5 log bacterial reduction (standard disinfection) on

exposure to hypochlorite but only 15 to 30% needles contaminated with bacteria

suspended in blood showed 5 log reduction in viable counts.

Thus, hypochlorite treatment is inadequate for disinfecting needles contaminated with

pathogenic bacteria in presence of blood and should not be recommended as an option

for disinfection of the needles.

According to Times News Network (2003) for almost two months the chimneys of bio

medical waste incinerator in Sewri’s TB Hospital have been spewing out pollutantsthat are almost 8 times higher than the permissible limit.

The BMC found that incinerator’s levels of particulate matter – the tiny particles

released from the chimneys – stood at 792 parts per mission ppm. The Maharashtra

Pollution Control Board’s standard for incinerator is 100 ppm. The water shower thatarrests the suspended particles had stopped functioning and failed to fitter the

pollutants.

The BMC warned the operators EA Infrastructure that it would suspend its contract if

things did not improve. After the repair of the scrub which washes the smoke, the air

in the chimney was found to have only 16 ppm.

Dogra Sapna (2004) in her article “30 govt hospitals incinerators spew lethal fumes”has described the status of incinerators in Delhi hospitals. She said that without

paying any attention to the Central Pollution Control Board’s directives, whichdiscourage the usages of incineration in hospitals Delhi hospitals continue to burn

their medical waste in onside incinerators. Currently there are about 30 incinerators

across the Delhi government and Municipal Corporation of Delhi (MCD) hospitals

that pose a threat to the health of the city’s population by releasing carcinogensthrough the burning of medical waste.

According to a survey conducted by Ravi Agarwal of NGO Toxics Link, most of

Delhi hospitals do not have pollution control equipment and thus do not meet

emission norms laid down by Central Pollution Control Board. Burning of waste of

any kind results in the emission of persistent organic pollutants like dioxins and furans

which causes health problems such as impairment of the nervous system, the

endocrine system and the reproductive system.

CPCB has recently issued guidelines on common bio-medical waste treatment facility

on the design & construction of bio-medical waste incinerators and discourages onsite

incinerators by allowing new incinerators only in certain inevitable situations.

The guidelines also limit the categories of waste that requires incineration as the

treatment option. According to Ravi Agarwal, the CPCB guidelines about the limits

of incineration have not been notified to hospitals (through an amendment in the rules)

and they continue to incinerate all categories of medical waste.

According to a senior doctor of Deen Dayal Upadhaya Government Hospital; the role

of incinerators cannot be written off in an Indian scenario though he admitted that

there are other alternative methods to incineration, but they are very expensive and

hence government hospitals are complying with the norms having understood the

harmful effects and high running costs of the incinerator along with the complexities

involved in meeting the emission standards. Holy Family hospital in the capital has

stopped using the incinerator and has started giving their medical waste to the

centralized facility as it is more economical.

World wide the incinerator industry has become unpopular. However, third world

countries like India are witnessing a spread of this dirty technology.

Environmental groups across the globe are resisting waste incineration and are

insisting that their government should put a stop to the deadly practice of burning the

medical waste.

Kamdar Seema I (2004) states that incinerators at Nagpur and Pune do not have

proper arrangement for ash disposal while in other cases, the required temperature for

incineration and autoclaving is not maintained. The incineration of bio-medical waste

at temperatures lower than the specified range is likely to emit toxic and carcinogenic

air pollutants like dioxins and furans. Hence, improper bio-medical waste incineration

at lower temperatures and lower residence time is more dangerous than not treating

waste.

Most of the studies investigate the status of incineration in big cities like Mumbai,

Delhi, Pune, and Nagpur. All these studies show that incinerators do not comply with

bio-medical waste management rules. As years passed, decline in number of

incinerators is noticed. Delhi hospitals still pose a threat to the health of city’spopulation by releasing carcinogen through the burning of medical waste even in the

year 2004. Hazardous medical waste is currently continued to be disposed off by

adding it to the garbage that creates dangerous levels of contamination.

2.12.0.0 Impact on Community/Society;

The end purpose of this research is to ensure diminishing impact on local population

of vagaries of hospital waste management. Various studies carried out are discussed

below.

SRISHTI an NGO in Delhi has been agitating for long against burn technology in auto

claves. Delhi administration has still not banned functioning of burn autoclaves.

THE HINDU April 2004 has given in Editorial that incinerators are the biggest

pollutants in Autoclaves.

RTEMIS Health Institute, Gurgaon spearheads in June 2012 infection control

Programme. She specializes in quality control in labs, healthcare, worker safety and

hospital acquired infections. She is instrumental in getting Asia Pacific Hand Hygiene

Excellence Award 2010-11. This is the only hospital in India to get this award.

NEERI Study carried out in 2004. This studied 174 people staying next to Gorai

dumping ground in Mumbai. The study revealed 9.2% increase in asthma and eye

irritation. This propagated concept of Advance Locality Management (ALM) so that

segregation is done at source.

Dignity Foundation of senior citizens has also been roped in Mumbai. 600 senior

citizens are keeping watch on conservancy sections, and motivate staff awareness in

students. Jayanath ST in Journal of Medical Microbiology,2009 says approx 3 million

people experienced Hepatitis C virus percutaneous.

Dr M Subbarao, Director Ministry of Environment and Forests is working on

minimizing environmental release of dioxins, Furans, Mercury. He is implementing in

2012 GEF-UNDP-MOEF Project on Hospital Waste Management in States of UP and

Tamilnadu. The outcome of this Project is out in March 2013.

C Vishwanathan, Environment Engineering and management Programme AIT,

Thailand, in 3R Conference on 31 October/01 November 2011 has suggested ways to

minimize medical waste at initial stages itself.

King George’s Hospital Lucknow, UP has won WHO-UNDP Award on 23 June 2013

for best practices in Hospital waste management. Best part is that it adopted locality

near central facility for safe guard against ill effects of autoclaving.

Palnitkar (1999) carried out a study to find Socio-Economic Status of the rag picking

women in Mumbai. The findings of the study are as follows :

Maximum number of the women rag pickers reported to fail sick, once

or twice a month while very few fall sick three times a month.

It was observed that health of woman rag pickers is affected mainly

due to poverty, their living conditions or due to the nature and their

work.

They generally suffer from sore eyes and inflammation due to

unconscious rubbing of eyes with the hands which they use for

picking up the garbage.

As they do not use protective measures for picking up garbage skin

disease are very common among them.

Waste being breeding ground of disease, coughing and sneezing are

very common and therefore they generally suffer from chronic cold or

lung disease. Cuts and injuries due to sharp objects in the garbage

results in infections and exposed skin, Even AIDS has been found to

be risk through accidental contact with the infected needles in the

garbage.

Desai Rajani (2001) in her study emphasized on increasing the awareness about

adverse impact of improper disposal of medical waste on community health amongst

doctors by organizing awareness programs, through different medical publications,

continuing education programs and seminars on medical waste. She also suggested

that medical waste should be included as a part of the curriculum for undergraduate

medical students and nurses.

Times News Network (2003) published that more than 200 school children and

resident from Chembur and Ghatkopar staged an angry demonstration outside the M

Ward Municipal office on Thursday 11th December 2003 to protest the civic

administrations in action with regard to the burning of the waste at the Deonar

dumping ground in north east Mumbai.

The hazardous smoke from the dumping around has long been a caused for

breathlessness, chest pain and other ailments for the locals, Beside the air pollution the

fumes also leave an unbearable stench in the air.

However, the administration of Brihan Mumbai Municipal Corporation (BMC)

appears to have done little to ensure a minimum of health, safety majors for taxpaying

citizens.

From the above discussion it is clear very few studies are carried out to show the

adverse impact of mismanagement of bio-medical waste. It is also evident that most

of the studies investigate the adverse impact of improper disposal of medical waste on

the rag pickers.

2.13.0.0. Efforts taken to Improve Hospital Waste Management:

After reviewing the shortcomings of medical waste disposal systems in the hospitals,

some of the researchers under took the studies to implement a system to improve

medical waste disposal.

V Srinivasulu (1998) in association with medical institutions and Nellore municipality

initiated a program for proper collection and disposal of hospital wastes from about 40

hospitals, nursing homes and clinics as medical waste was dumped in the municipal

dustbins or roadside along with other municipal waste causing serious health and

environmental problems in Nellore town.

Under this program, medical waste was collected from the premises of hospitals by 2

cycle- rickshaws manned by two “green soldiers” and supervised by one “green

supervisor”. There was an additional worker at the dumping yard site. The servicewas maintained by contribution given by the hospitals and clinics at about Rs 150/per

nursing home and Rs 60/ per clinic.

The project had the following components :

The segregation at source, and collection of Bio medical waste from

the premises of the institution.

Infrastructure at municipal yard; ie establishment of a microwave

treatment plant and a burial site at the municipal dumping yard.

Training programs and citizen’s awareness campaign were organized.

Training should impart knowledge about legislation covering hospital waste

management.

Ganguli Anita (1999.) Health Institutions were notified by the Centre in 1998 that

implementation of the biomedical waste rules must be complete across the country by

December 31 1999 through the offices of Director General (Health Services), Indian

Medical Association, New Delhi Medical Association and Indian Counsel of Medical

Research, all the hospitals were asked to initiate steps in a graded manner.

The reality, however, is different. Quick and easy disposal till now is in the form of

municipal land fills and low technology – incineration dumped on Indian users from

the west, which adds to the unsatisfactory disposal majors by emitting toxic fumes

such as dioxins and furans into industrial waste polluted atmosphere.

At this time, Tata Memorial Hospital took a lead and Asia’s first hydroclave forbiomedical waste disposal was installed on September 10, 1999 in the premises of the

Hospital.

Verma LK, Srivastava JN (1999) carried out a WHO aided pilot project at Command

Hospital of Air Force (CHAF), Bangalore. This project is a trend setter in the field of

hospital waste management in this country. It was experienced that CHAF Bangalore

was not practicing safe disposal of bio-medical waste. It was also reported that 30%

of respiratory disease are prevalent due to environmental pollution and 30% to 40%

morbidity amongst safai Karamchari, ward boys or rag pickers take place because of

inappropriate disinfection and disposal of medical waste.

With this in mind a pilot project CHAF Bangalore was undertaken. At CHAFB,

waste generated at all points of generation was quantified and categorized into four

groups namely Human tissues, general waste, infectious waste, and plastics. Data

collected from each generation point was analyzed quantitatively. It was found that

average waste generated at CHAFB was 1.224 Kg/bed/day. During the study, it was

found that there was lack of awareness amongst the health care planners, Ward boys,

safai karamcharis, doctors and nursing staff also showed nonchalant attitude towards

the problem.

Hence, awareness was inculcated amongst all strata of health care planners and

handlers by organizing repeated lectures, talks, workshops and poster. Due to these

efforts, a desired change was noticed in the level of awareness amongst all.

Due to one or other limitation in all types of technological options, a multiple option

approach for hospital waste disposal was adopted. Microwave, Autoclave, incinerator

and Hydroclave were used for disposal of waste but Hydroclave system is the

mainstay for disposal of waste at CHAF Bangalore. A standard format for the

movement of waste was made available to all the healthcare workers which indicated

movement and interventions for safe disposal of medical waste in the hospital.

Protective clothing for waste handlers were provided. As an offshoot of the pilot

project vermin-composting of infected waste is being practiced.

Tripathy BC (1998 to 2000) investigated hospitals waste management under Orissa

Health systems Development project.

The objective was to introduce a three phase action plan in hospital waste

management in 156 project hospitals in secondary and primary levels in the state of

Orissa in consonance with the Ministry of Environment and Forests Rules and in

agreement with the World Bank. The activities undertaken were as follows:

State and district level workshops are organized from time to time.

Technology support for implementation of the plan is given.

Training in hospital waste management is given.

Consultancy for hospital waste management is finalized.

District micro – plans for implementation of process have been

finalized.

Funds for implementation of hospital waste management have been

released to districts.

The segregation at source, and collection of Bio medical waste from

the premises of the institution.

Saxena DB, Jagdish R, Kamath (2000) studied Medical waste management in four

Hospital of Vadodra. Before any statutory legislation in the country, GEC pilot study

with the help of Baroda Management Association, helped four hospitals in Vadodra to

adopt cost effective, scientific, eco-friendly medical waste plan which was tailored to

their respective needs.

The following steps were taken :

Disinfection of needles, and syringes.

Cutting all the plastic tubing immediately after use.

Use of personnel protective measures

Putting every waste in the bin.

Transporting waste without spillage.

Kela Megha, Goel Anu (2000) from Srishti undertook a case study of Holy Family

Hospital in Delhi. Holy family hospital is a 300 bedded municipality hospital offering

Allopathic, Homeopathic and Ayurvedic systems of treatment. After realizing the

problem caused by hospital waste, the hospital administration took initiative to build a

waste management system in the hospital along with Srishty.

Following steps were taken to build the sound waste management system:

A survey was carried out to get deep insight on the present waste

management practices of the hospital.

The order for the number, type and size of bins, their positions at each

point of generation, needle destroyers, forceps and scissors for holding

and cutting the used plastics, protective gear for personnel handling

was detected after the survey.

Training sessions for the nurses, nursing students, laboratory and

house keeping staff was carried out before and after the

implementation of waste management system.

Dolas Sanjay Kumar (2000-2001) studied medical waste disposal practices in

Rajawadi hospital, Mumbai. The researcher arrived at the following conclusions:

Hospitals waste management is moral, ethical and legal duty of each,

and every medical personnel.

Precautious handling of bio-hazardous infection waste is minimized

by proper waste management, and segregation of waste at source.

Arrangement of proper training of the staff by public health

department has improved awareness of importance of waste

management in Rajawada Hospital.

Appointment of medical officer-in-charge, sanitary inspector, sweeper

helped to organize and supervise the hospital waste disposal policy.

Rajawadi Hospitals follows the slogans Reduce, Reuse, Recycle

In Rajawadi hospital, all the practical problems associated with

medical waste management are identified, and analyzed properly.

The waste audit is carried out regularly.

The sharps are treated in 2% hypochlorite solution, and sent for

incineration as per rules.

The infectious bio-hazardous waste is handled, collected, stored,

transported and finally incinerated at Sewri incineration plant as per

the published notification on bio-medical waste (management &

handling) rules 1998 dated 20th July 1998 and thus the non infectious

waste is prevented from becoming infectious waste.

Vijaya K (2001) in her article, “A commendable achievement in waste management”has described about distinguished contribution of Air Force Command Hospital to the

Health Care Sector and has achieved distinction of being only hospital out of chosen

12 in the country to meet the WHO deadline for implementing hazardous waste

management.

Air Marshal LK Verma was the principal worker of this project and following steps

were taken to achieve the goal of development of a system of safe collection, storage,

transportation and proper disposal of hazardous hospital waste;-

Awareness about hospital waste management was created among all

sections of the hospital staff.

Sources of waste generation, the quality and quantity of waste was

identified.

A comprehensive system of waste disposal was laid down.

A systematic approach and standard operative procedure were adopted

for effective and safe disposal of hospital waste.

Training was given to the paramedical staff, doctors, nursing staff and

other waste handlers.

All the wastes are disposed in different modalities.

The process basically involved proper segregation and disinfection of

the waste.

Syringes are quashed. The broken needles and sharps are disinfected

in hypochlorite solution and treated with lime before being buried.

Needles and syringes are destroyed immediately by means of needle

destroyer cum needle cutter.

The waste handlers use protective gear.

The hospital waste management project which was successfully completed at an

estimated cost of Rs One crore has changed the hospital environment as given below :

Improved the general cleanliness of the hospital; both from within the

wards and general environment of the hospital.

Dogs, cats, birds and rodents menace have considerably decreased.

Incidences of hospital acquired infections are reduced and the average

stay of the patients in the hospital has become less.

Postoperative infections have also dropped,

The command hospital is now trying to study the advanced vermin-composting so as

to convert infected waste into manure.

Deshmukh Smita (2004) in her article “To Die for -------? Highlighted the current

issue of treatment, and disposal of bio-medical waste by Mumbai hospitals.

Medical and environment experts are dubbing it as a volcano ready to explode.

Mumbai with 1,351 hospitals and 35000 beds generate 10 tones of biomedical waste

daily, and has no full fledge facility to treat and dispose it off.

This hazardous medical waste is currently being disposed of by adding it to garbage.

This creates dangerous levels of contamination with tissues and infectious material

like bandages, syringes and blood bags getting mixed with solid waste, which is a

perfect formula for health disaster.

Taking note of this danger the MPCB has now sent showcase notices to 561 city

hospitals for not complying with the guidelines for treating medical waste. There is

enough evidence to link the growing cases of viral infections in the city to this cross

breeding of bacteria and virus caused by this mixing of waste.

The disposal crisis has manually arisen due to tug of was between the MPCB and the

Brihanmumbai Municipal Corporation, due to shutting down of incinerator at Sewri.

This incinerator caused serious health problems to the local residents. The transporter

involved was also recently caught removing used syringes from the waste.

Horrifyingly those were to be sold for reuse. So, MPCB decided to assign this task to

a professional agency which should follow an integrated approach of collection,

transport and treatment.

It was also felt that Mumbai needs three sites to treat medical waste in eastern,

western and southern areas and impact assessment study of each site will be done by

an expert committee.

Looking at the scary picture of improper management of infectious sharps, Agarwal

Anu (2004) in her article “Roundtable on immunization Waste Disposal” hasdescribed some of the important recommendations formulated during the roundtable

meeting on “Immunization waste disposal” held on August 19 at India Habitat Centre.The meeting was attended by the Secretary, Ministry of Health and Family Welfare,

as well as by representatives from the World Health Organization, World Bank,

Health Care without Harm, PATH, USAID, government officials and several other

medical professionals.

As a result of the meeting, several important recommendations were formulated as

given below :-

Removal of separation of needle and syringe at point of use: The

needles should be separated from the plastic syringe at the point of

administration of the vaccine, using a needle cutter or a needle puller.

Sharps pits at PHC : Syringe pit for standardized containers (which

can contain sharps securely and can be stored over ground) need to be

located at the primary health centres (PHC).

Disinfections of plastic portion of syringe: as per the CPCB, under the

existing law, it is required that the plastic portion be considered

infectious and be disinfected accordingly. However, the group

recommends that a study be carried out to determine if the plastic

portion is actually infectious or not, since some experts have

expressed an opinion that these may not require disinfection. Future

action about disinfecting this syringe should be taken after such a

study has been carried out.

Phased implementation: Some members of the group felt that there

could be several challenges to do a one time introduction of A/D

syringes in the whole country. These challenges include supply of

equipment, training of nursing staff, materials, costing issues, etc. It

was expressed that it may be considered that a phased grogram in the

country in a step by step level be carried out.

Product group : It was recognized that equipment such as needle

cutters and pullers need to be standardized, to ensure that they

function for an effective period of time, such as a year, BIS needs to

be roped in quickly by MoH * FW & CPCB for working out

standards, given the urgency of the matter.

Micro planning: Most members in the group recommended that since

there will be several types of situations on the ground and several site

specific requirements, the processes be done through ground level

micro planning which will also ensure involvement of a larger number

of local stake holders.

Cost: While designing these waste management methods, their

practically and affordability at ground level should be considered.

Kashyap Siddharta S (2004) BJ Medical college dean said that the bio medical waste,

needles and syringes were being segregated at source and treated in their hospital. The

hospital currently has a bio medical waste incinerator, and is planning to install a state

of the art Hydroclave that will run parallel to the incinerator to treat the large quantum

bio medical waste generated every day.

Mumbai Med Waste Action Group (2005) submitted a petition on 28th July, 2005 to

the member secretary of Maharashtra Pollution Control Board (MPCB) as he had

sanctioned four new bio medical waste incinerator projects under the guise of a

common waste treatment plant. The petition clearly states that in order to minimize

the environmental and public health consequences of the common bio-medical waste

treating facilities.

MMWAG in 2005 strongly recommended that the following points should be

incorporated in the MPCB’s protocol for bio medical waste management anddevelopment of new common bio medical waste treating facilities in Mumbai.

No more incinerators for city of Mumbai.

Increased monitoring and regulation of waste from hospitals to the

sites and from sites to the land fills.

Selection of any new site.

Site selection committee shall be constituted.

Public hearing on site selection.

Monitoring of the selected sites.

Minimising waste so that there is less waste to treat at the end.

MPCB’s role in waste management should include efforts to reducewaste.

Dealing with public concerns, and complaints.

The report concluded with recommendations and a proposed plan which incorporated

specific time frames for the various activities. Some of the recommendations and

activities that were to be immediately undertaken by MPCB include:

Monthly inspection, and monitoring of common bio-medical waste

treating facilities.

Issuance of directions to upgrade all the units in the facilities to the

prescribed standards, and to install online temperature recorders for

the incinerators.

Legal actions against generators who are not sending waste to the

facility or who are not segregating waste properly.

Establishment of a legal task force for monitoring, and advice,

comprising of representatives from the IMA, from the local body,

from NGOs and the State Health Department.

Inventory of Bio-medical waste generating units and category wise

waste generated.

Express Healthcare Management Bureau (2005) of Bangalore in their article “Manipalto establish centre of excellence in waste management” informs that ManipalEducation and Medical Group (MEMG) has signed an understanding with Deuttsche

Gesellschaft for Technis Zusammenarbeit, Germany to establish first of its kind state

– of the art centre of excellence in waste management at Manipal Hospital.

This centre will develop intellectual properties in the field of environment

management, while Manipal Academy of higher Education (MAHE) will offer

diploma courses in the area of environment and waste management.

The centre will show case world class bio medical waste management including

segregation, collection and disposal, effluent treatment and Environment Management

System (EMS) and thus the centre of excellence for waste management will set new

benchmark for healthcare industry in India.

The centre will be open to all the hospitals in India for visits and results will be

available as case studies. The centre will conduct work shops, seminars, and training

across the country to create awareness about waste management. Manipal Group

plans to play the role of advisory and assist other hospitals to establish similar waste

management systems. The benefit of the new systems include water saving and

consumption minimisation. The system will work for both solid and liquid waste.

The new system will also upgrade the existing systems at Manipal hospital for

certification as per ISO 14000 protocol.

This will be used by MAHW to offer Diploma Courses on subjects

such as : Bio medical waste management including segregation,

collection and disposal.

Effluent treatment including collection, treatment, and disposal.

Environment Management System (EMS) implementation, and

operation.

Kelkar Suhit (2005) said that faced with growing problem of how to dispose of piles

of bio medical waste, the Brihan-mumbai Municipal Corporation (BMC) has short

listed seven sites in the city to set up three to four waste disposal centres. Tenders for

the waste disposal proposal are being scrutinized by Maharashtra Pollution Control

Board, the consultant for the bio medical waste disposal project.

The western and the eastern suburbs will get a centre each while the city may get two.

Each centre will cater to between 80,000 to one lakh beds. The short listed site are :

Vaikunthdham Cemetery at Mazgaon, the Hindu cemetery at E Moses Road, Chetah

camp and Marve Road, a recreational ground plot at Anik Village at the Malad

lagoons, Deonar dumping ground.

According to the project proposal document, the centre will be run by private

operators without any capital or manpower contribution from BMC. The operator

will also have to transport the waste from the hospital to the centre. The

municipality’s role is restricted to leasing land to operators and water to the centers.

Hospitals will also have to pay more Rs 40 per kg of medical waste as opposed to the

earlier Rs 18/- per kg.

Staff reporter (2005) of Express Health Care Management in his article “Hospitals

may have to improve waste management in Kochi” states that Kochi Corporation hasdecided to act tough against hospitals that lax in disposing of wastes generated by

them. The corporation will issue notices to hospitals, asking them to pay for the waste

to the disposed off or dispose it on their own, said the Deputy Mayor, AV George.

The corporation has included a proposal to this effect in its annual budget, which was

passed recently. The notices will be issued by next week, he said.

According to through estimate, the corporation removes 10 loads of wastes a day from

hospital premises. A leading hospital generates three loads every day.

According to civic administrators, the efforts to set up an incinerator at Brahmapuram,

where 100 acres of land had been bought for setting up a solid waste treatment

facility, failed to evoke a positive response from hospitals.

Despite protests from environment group and the Indian Navy, the corporation has

resumed dumping of waste on two sites owned by the Cochin Port Trust at the Kochi

estuary near the Kundannoor – Thevara bypass. The Naval authorities had objected to

dumping of waste on the sites as they were near the Naval airport. This may cause

damage to aircraft by bird hits. Earlier, the port trust had asked the corporation to stop

the practice.

However, 100 loads of waste are being dumped there now. Mr George said that the

civic body had been dumping wastes on these sites in a scientific manner after

spending a considerable sum.

The corporation had no other way to dispose of waste till the Brahmapuram project is

completed. If the state government cleared the project, the site could be used for

dumping waste and setting up the plant.

Roy Vijay, Gupta Puneet, Joshi (2005) in their article “Practical guidelines for

disposing cytotoxic waste” have explained the method of safe disposal of cytotoxicwaste. Prior to looking at waste disposal there are whole series of set ups in the

management of chemotherapy drugs such as inventory management, preparation,

storage, administration and waste segregation that results in minimizing the amount

and type of material that needs special disposal. Most of the cytotoxic drug waste is

in minimal quantities remaining in vials, in tubing and IV bags, on gloves, gowns,

gauze and syringes. In these forms, a small quantities are hard to extract from the

materials (and very dangerous) and no amount of water deactivates them. The

chemotherapy drug waste being cytotoxic in nature kill cells very effectively and

therefore needs to be handled with special care.

The cytotoxic waste is highly hazardous and should never be land fill or discharged

into the sewage system and following options can be followed for disposal of

cytotoxic drugs.

Return to original supplier – safety packed but out dated drugs should

be returned to the supplier.

Drugs that have been unpacked should be repacked in a manner as

similar as possible to the original packaging and marked “outdated” or“not for use”.

Incineration at high temperatures – full destruction of all cytotoxic

substances may require temperature up to 1200ºC with a minimum gas

residence time of 2 seconds or 1000ºC with a minimum of gas

residence time of 5 seconds in the second chamber. Incinerator at

lower temperatures may result in the release of hazardous cytotoxic

vapors into the atmosphere. The incinerator should be fitted with gas

cleaning equipment.

Chemical Degradation – chemical degradation methods which convert

cytotoxic compounds into non toxic / non genotoxic compounds, can

be used not only for drug residues but also for cleaning of

contaminated urinals, spillage and protective clothing.

It should be noticed that neither incineration nor chemical degradation currently

provides a completely satisfactory solution for the treatment of waste, spillage or

biological fluids contaminated by cytotoxic agents. Here neither high temperature

incineration nor chemical degradation methods is available, encapsulation or initiation

may be considered as a last resort.

Times of India report (2007) revealed that Mumbai has 1354 private, 293 municipal

and 12 government hospitals and generate about 10 tons of bio medical waste in form

of human and animal anatomical parts, tissues, fluids, solid waste, syringes and other

material.

The public interest Litigation (PIL) filled by the Consumer Welfare Association

focused on how rules were flouted. A MPCB report filled in the high court revealed

that, of 366 government hospitals in the state a substantial 162 were found to be

violating bio medical waste disposal rules. Around 239 governmental hospitals did

not even have autoclave machine that is required to dispose the waste generated.

During the course of the hearing the judges remarked on the pathetic conditions

prevalent in many government hospitals and added that many people preferred to die

at home rather than go to a government hospital.

The Bombay High Court on Wednesday 7th March 2007 asked the Maharashtra

Government to come out with a statement on when it would get all public hospitals to

conform to the rules for management and disposal of bio-medical waste. Hearing a

Public Interest Litigation on the lack of proper disposal facilities, a division bench of

acting Justice JN Patil, and Justice SC Dharmadikari also asked Maharashtra Pollution

Control Board and the BMC to file affidavit in this.

Times of India reporter (2007) published a hearing on Public Interest Litigation filed

by the Consumer Welfare Association on the improper disposal of bio medical waste.

A division bench of chief justice Swatanter Kumar and Justice SC Dharmadhikari

directed the state’s two top health officers to visit all government and private hospitalsin Mumbai and verify whether they have implemented facilities for managing and

disposal of bio medical waste and submit a report on the issue in four weeks.

The court also asked the government to depute officers to inspect bio medical waste

disposal facilities in hospitals across the state and submit a report in six months. The

judges remarked that mere legal compliance of law and rules on paper per se would

not serve the public interest, the state has to ensure that instructions issued to dispose

of waste are carried out in the day to day working of each hospital.

The Economic Times (2007) published an article “HC raps health department on bio

medical waste disposal issue” stating that the Bombay High Court took theMaharashtra Government to task over an affidavit of its health department regarding

implementation of bio medical waste disposal in hospitals across the state.

A division bench of Chief Justice appointed two lawyers as court commissioners to

inspect 10 hospitals each with in Mumbai.

The High Court was miffed over by the fact that the affidavit of the Director, Health

Services was silent on whether the Government had dealt with objections raised by the

Maharashtra Pollution Control Board on waste disposal stating that many hospitals did

not have proper deep burial pits required under the law.

The Chief Justice said that “The affidavit is virtually false – and you are playing with

people’s health. He also added that the two court commissioners should visit fivegovernment and the five private hospitals and should be accompanied by a person

nominated by the MPCB secretary with doctor nominated by the director of health

services and file report before the court.

The order came during the hearing of PIL filed by city based Consumer Welfare

Association, which complained that a majority of the hospitals in the state did not

dispose of bio medical waste in the way prescribed by the bio-medical waste disposal

rules 1998.

2.14.0.0 Conclusion

After reviewing the related literature, we find that many studies have been undertaken

in the field of the systems adopted for managing the biomedical waste in the hospitals

all over the country, but more efforts are needed to study the role of different

technologies in rendering the infectious waste into non-infectious waste. Very few

studies have been carried out to show the adverse impact of mismanagement of

biomedical waste on the health of hospital personnel and the community as whole in

our country.

Further, it is noted that most of the studies undertaken to assess the implementation of

the biomedical waste systems already initiated present a very gloomy picture. Many

hospitals do not have proper scientific systems of medical waste disposal. At the heart

of a medical waste crisis looming over the country is the inability of the hospitals to

segregate medical waste effectively. The health care workers are still confused about the

colour coding of medical waste bags. Most of the hospitals do not have proper sharp

management policy as a result in majority of the hospitals, needles and syringes are not

separated, cut, or burnt. The used syringes are not disinfected before its disposal. The

used gloves are neither cut, nor disinfected.

The transportation of the biomedical waste from the wards to the storage place is not done

correctly.

Occupational health and safety issues still remain a major area of concern. The health care

workers are not aware of the health hazards which may occur due to mismanagement of

the biomedical waste.

Many hospitals still continue to dump their infectious waste into municipal bins due to non

availability of services extended by the municipal corporations in most of the cities.

Most of the studies are carried out to investigate the functioning of incinerators in big cities

like Mumbai, Delhi etc. These studies reveal that majority of the incinerators fail to

comply with the bio medical waste disposal rules and operated at lower temperature which

in turn release the toxic emissions thus polluting the environment. Very few studies have

been undertaken to find out the cost effectiveness of various treating technologies. Such

as autoclaves microwaves, chemical disinfection, hydro clave incinerators etc.

Thus, lots of efforts are needed to take up the studies to show the ill effects of

mismanagement of biomedical waste on all the health care workers and community as

whole. Most of the studies undertaken reveal the effect of mishandling of biomedical

waste on only rag pickers.

The investigator thus felt that lots of efforts are still required for management of

biomedical waste in hospitals all over our country. The next chapter gives the

methodology followed to carry out the research.